Improving mental health through parenting programmes: block randomised controlled trial

Impact on Maternal Postpartum Depressive Symptoms of a Primary Care Intervention Promoting Early Language: A Pilot Study

OBJECTIVES

Maternal depressive symptoms are an important risk factor for adverse child outcomes, especially in the perinatal period. We studied whether introducing finger puppets in the primary care setting to promote infant language improves maternal postpartum depressive symptoms.

METHODS

An intervention cohort was enrolled and given a finger puppet at the 2-month infant well visit. Two usual care cohorts were enrolled at either the 6- or 12-month well visit as part of a larger study. Depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS), which was administered by clinic providers as part of routine screening done at both the 2- and 4-month well visits. EPDS scores were obtained retrospectively through the electronic medical record.

RESULTS

Included mothers (n = 127) completed the EPDS at 2 and 4 months postpartum. Most children (83%) were on government-sponsored insurance. Mean EPDS scores and scores classified as possible depression (≥ 10) did not differ between cohorts. However, the change in scores between visits was significantly different for intervention (n = 46) compared to usual care (n = 81) participants (-1.1 vs. +0.4, p = 0.001). More intervention scores improved (n = 17, 37%) compared to usual care (n = 14, 17%), while more usual care scores worsened (n = 28, 35%) compared to intervention (n = 6, 13%) (p = 0.008).

CONCLUSION

Finger puppets introduced during infant primary care visits to support language-rich maternal-infant interactions may provide a simple, low-cost way to improve maternal postpartum depressive symptoms. Larger studies with more diverse populations are needed to determine if effects are replicable, generalizable, and translate into better clinical outcomes.

Changes in Prosocial Behaviors Among Children With Behavioral Problems Following Incredible Years Parenting Program

Parenting programs often train parents in improving their parenting practices and parent-child relationship to reduce behavioral problems in children. However, the children's prosocial behaviors are less examined as an intervention outcome in these programs. This study aimed to evaluate the effectiveness of the Incredible Years parenting program (IYPP) for Malaysian parents of school-going children and its sustainability in improving the children's prosocial behaviors. This randomized controlled study involved pre- and post-intervention assessments at 2 and 14 weeks. Mothers of children aged 6-12 years (n = 70) recruited through the pediatrics and the child and adolescent psychiatric clinics were randomly assigned to the parenting program or a waitlist control condition. The mothers rated their children's prosocial behaviors using a self-administered questionnaire. The program ran two to three hours weekly for 14 weeks. Several modifications were made to the program to accommodate public health control during the pandemic. Children in the intervention group showed a notable but non-significant increase in prosocial skills. However, subsequent score decline at follow-up may suggest a lack of evidence that the program is potentially effective in improving prosocial behaviors among school children who are at risk of or already having behavioral problems.

Mostly worse, occasionally better: impact of COVID-19 pandemic on the mental health of Canadian children and adolescents

This large cross-sectional study examined the impact of COVID-19 emergency measures on child/adolescent mental health for children/adolescents with and without pre-existing psychiatric diagnoses. Using adapted measures from the CRISIS questionnaire, parents of children aged 6-18 (N = 1013; 56% male; 62% pre-existing psychiatric diagnosis) and self-reporting children/adolescents aged 10-18 (N = 385) indicated changes in mental health across six domains: depression, anxiety, irritability, attention, hyperactivity, and obsessions/compulsions. Changes in anxiety, irritability, and hyperactivity were calculated for children aged 2-5 years using the Strengths and Difficulties Questionnaire. COVID-19 exposure, compliance with emergency measures, COVID-19 economic concerns, and stress from social isolation were measured with the CRISIS questionnaire. Prevalence of change in mental health status was estimated for each domain; multinomial logistic regression was used to determine variables associated with mental health status change in each domain. Depending on the age group, 67-70% of children/adolescents experienced deterioration in at least one mental health domain; however, 19-31% of children/adolescents experienced improvement in at least one domain. Children/adolescents without and with psychiatric diagnoses tended to experience deterioration during the first wave of COVID-19. Rates of deterioration were higher in those with a pre-exiting diagnosis. The rate of deterioration was variable across different age groups and pre-existing psychiatric diagnostic groups: depression 37-56%, anxiety 31-50%, irritability 40-66%, attention 40-56%, hyperactivity 23-56%, obsessions/compulsions 13-30%. Greater stress from social isolation was associated with deterioration in all mental health domains (all ORs 11.12-55.24). The impact of pre-existing psychiatric diagnosis was heterogenous, associated with deterioration in depression, irritability, hyperactivity, obsession/compulsions for some children (ORs 1.96-2.23) but also with improvement in depression, anxiety, and irritability for other children (ORs 2.13-3.12). Economic concerns were associated with improvement in anxiety, attention, and obsessions/compulsions (ORs 3.97-5.57). Children/adolescents with and without pre-existing psychiatric diagnoses reported deterioration. Deterioration was associated with increased stress from social isolation. Enhancing social interactions for children/adolescents will be an important mitigation strategy for current and future COVID-19 waves.

Prevention of child mental health problems through parenting interventions in Southeastern Europe (RISE): study protocol for a multi-site randomised controlled trial

BACKGROUND

Childhood adversities, such as poor parental practices, exposure to violence, and risk behaviours strongly impact children's future mental and behavioural problems. Adversities affect families living in disadvantaged environments and low- and middle-income countries (LMICs) to a greater extent than in high-income countries. Parenting programmes are an effective way to alleviate them, although their outreach and scalability is still limited in LMICs.

METHODS/DESIGN

A multi-site randomised controlled trial will be conducted in North Macedonia, Republic of Moldova and Romania to test the efficacy and cost-effectiveness of an optimised version of the promising Parenting for Lifelong Health Programme for Young Children (PLH-YC, 5 sessions), against a standard lecture on parenting issues (control group, 1 session). At least 864 participants who report having children between 2 and 9 years old who display elevated levels of behavioural difficulties will be randomised on a 1:1 basis to the intervention and control groups. The primary outcome will consist of parent report of child oppositional aggressive behaviour. Post-test (four months) and follow-up (12 months) assessments will provide information on short- and longer-term effects of PLH-YC compared to the parenting lecture in the control group.

DISCUSSION

This randomised trial will test the efficacy of PLH-YC in alleviating child behavioural problems and assess the cost-effectiveness, transportability across three different cultural contexts, and potential for scalability of the programme.

TRIAL REGISTRATION

ClinicalTrials.gov ., Registration number: NCT04721730 ( https://clinicaltrials.gov/ct2/show/NCT04721730 ). Registered 13.01.2021.

Effectiveness of family-focused home visiting for maternal mental illness: A systematic review and meta-analysis

WHAT IS KNOWN ON THE SUBJECT?: Maternal mental illness reduces a mothers' ability to bond with their infant and may adversely affect other family members. Family-focused practice is an approach which has the potential to support mothers with mental illnesses and reduce the risk of familial transmission of mental illness to children. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Findings suggest that current interventions are not effective in reducing depression or stress among mothers. The majority of interventions included in this review employed relatively low levels of family-focused practice. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: While there is a growing integration of family-focused practice into home visiting guidelines, this may be based on poor evidence. There is a need for the development of rigorously tested interventions which seek to include the whole family. ABSTRACT: Introduction The evidence on effectiveness of family-focused home visiting for maternal mental illness has yet to be comprehensively synthesized. Aim The aim of this study was to assess current home visiting treatments and interventions for mothers with mental illness and their families. Method The primary and secondary outcomes of interest were depression and maternal stress, respectively, both were included in meta-analyses. We identified 13 (n = 5,540 participants) studies which met inclusion criteria. Eight studies were included in meta-analyses; five studies were reported narratively. Results Findings from the meta-analysis suggest that home visiting interventions are not effective in reducing depression (SMD -0.13, 95% CI -0.33 to 0.07, p = .21) and maternal stress (MD 0.59, 95% CI -5.19 to 6.38, p = .84). Discussion and Implications for practice Findings suggest that current interventions are not effective in reducing depression or stress among mothers. While there is a growing integration of family-focused practice into home visiting guidelines, this may be based on poor evidence.

Screen Use and Mental Health Symptoms in Canadian Children and Youth During the COVID-19 Pandemic

IMPORTANCE

Longitudinal research on specific forms of electronic screen use and mental health symptoms in children and youth during COVID-19 is minimal. Understanding the association may help develop policies and interventions targeting specific screen activities to promote healthful screen use and mental health in children and youth.

OBJECTIVE

To determine whether specific forms of screen use (television [TV] or digital media, video games, electronic learning, and video-chatting time) were associated with symptoms of depression, anxiety, conduct problems, irritability, hyperactivity, and inattention in children and youth during COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

A longitudinal cohort study with repeated measures of exposures and outcomes was conducted in children and youth aged 2 to 18 years in Ontario, Canada, between May 2020 and April 2021 across 4 cohorts of children or youth: 2 community cohorts and 2 clinically referred cohorts. Parents were asked to complete repeated questionnaires about their children's health behaviors and mental health symptoms during COVID-19.

MAIN OUTCOMES AND MEASURES

The exposure variables were children's daily TV or digital media time, video game time, electronic-learning time, and video-chatting time. The mental health outcomes were parent-reported symptoms of child depression, anxiety, conduct problems and irritability, and hyperactivity/inattention using validated standardized tools.

RESULTS

This study included 2026 children with 6648 observations. In younger children (mean [SD] age, 5.9 [2.5] years; 275 male participants [51.7%]), higher TV or digital media time was associated with higher levels of conduct problems (age 2-4 years: β, 0.22 [95% CI, 0.10-0.35]; P < .001; age ≥4 years: β, 0.07 [95% CI, 0.02-0.11]; P = .007) and hyperactivity/inattention (β, 0.07 [95% CI, 0.006-0.14]; P = .04). In older children and youth (mean [SD] age, 11.3 [3.3] years; 844 male participants [56.5%]), higher levels of TV or digital media time were associated with higher levels of depression, anxiety, and inattention; higher levels of video game time were associated with higher levels of depression, irritability, inattention, and hyperactivity. Higher levels of electronic learning time were associated with higher levels of depression and anxiety.

CONCLUSIONS AND RELEVANCE

In this cohort study, higher levels of screen use were associated poor mental health of children and youth during the COVID-19 pandemic. These findings suggest that policy intervention as well as evidence-informed social supports are needed to promote healthful screen use and mental health in children and youth during the pandemic and beyond.

The Efficacy of Parent Training Interventions for Disruptive Behavior Disorders in Treating Untargeted Comorbid Internalizing Symptoms in Children and Adolescents: A Systematic Review

Disruptive behavior disorders (DBDs) are among the primary reasons for child and youth referrals to mental health services and are linked to poor adult outcomes including antisocial behavior disorder. Research indicates a high incidence of internalizing problems in those with DBDs and those who have DBDs with cooccurring internalizing problems may have more severe later outcomes. Interventions targeted at internalizing symptoms have been found to also reduce comorbid externalizing problems. The impact of treatments for DBDs on comorbid internalizing disorders is not known. Databases PsycINFO, EMBASE and MEDLINE were systematically searched based on the Cochrane guidelines for systematic reviews. Records were independently reviewed by two reviewers. 12 papers were deemed eligible. A quality assessment of the selected studies was conducted independently by both reviewers. The 12 studies included 1334 young people with a mean age of 5 years. The parent training interventions assessed were the Incredible Years (6/12 studies), Triple-P (5/12) and Tuning In To Kids (1/12). 11 of the 12 studies reported significant reductions in primary externalizing behavior problems and DBDs. 7 studies reported significant reductions in internalizing symptoms. Mechanisms of change, clinical implications and directions for future research are discussed.

A Systematic Review of External Validity in Pediatric Integrated Primary Care Trials

OBJECTIVE

We used the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to conduct a systematic review of external validity reporting in integrated primary care (IPC) interventions for mental health concerns.

METHODS

We searched Medline, CINAHL, PsycINFO, the Cochrane Center Register of Controlled Trials, and relevant literature to identify publications from 1998 to 2018 reporting on open, randomized, or quasi-randomized trials of IPC interventions that targeted child (ages 0-18 years) psychological symptoms. For each publication, we extracted the information reported in each RE-AIM domain and calculated the proportion of the total studies reviewed.

RESULTS

Thirty-nine publications describing 25 studies were included in the review. Publications rarely reported some indicators of external validity, including the representativeness of participants (12%), rate of adoption clinics or providers (16%), cost of implementation (8%), or evidence of maintenance (16%). Few studies reported on key pragmatic factors such as cost or organizational change processes related to implementation and maintenance. Strengths of some studies included comparisons of multiple active treatments, use of tailorable interventions, and implementation in "real world" settings.

CONCLUSIONS

Although IPC interventions appear efficacious under research conditions, there are significant knowledge gaps regarding the degree to which they reach and engage target recipients, what factors impact adoption and implementation of IPC interventions by clinicians, how fidelity can be maintained over time, and cost-effectiveness. Pediatric IPC researchers should embrace dissemination and implementation science methods to balance internal and external validity concerns moving forward.

Individual Participant Data Meta-analysis: Impact of Conduct Problem Severity, Comorbid Attention-Deficit/Hyperactivity Disorder and Emotional Problems, and Maternal Depression on Parenting Program Effects

OBJECTIVE

There is concern whether established parenting programs for children's conduct problems meet the needs of families with severe and complex mental health problems. For example, many children with conduct problems show comorbid attention-deficit/hyperactivity disorder (ADHD) or emotional problems, or have parents who are depressed, but families with such complex mental health problems typically seen in real life are often underrepresented in evaluation trials. We tested whether children with more severe conduct problems, and those with more complex mental health problems, benefit less from the Incredible Years parenting program, using individual participant data meta-analysis of randomized trials in Europe.

METHOD

In 1,696 families from 13 children aged (child age 2-11 years; 37% girls; 58% low income; 30% ethnic minority; 98% mothers), we used moderator analysis within a multilevel model to test whether initial conduct problem severity, comorbid ADHD or emotional problems, and maternal depression would diminish intervention effects for children's conduct problems.

RESULTS

The Incredible Years program reduced children's conduct problems overall (Cohen's d = -0.35), but more so in children with more severe conduct problems. There was no evidence that children's comorbid ADHD and emotional problems changed the intervention benefits. Children of mothers with more depressive symptoms benefited more.

CONCLUSION

Children with more severe conduct problems derive greater, rather than lesser, benefits from a high-quality group parenting program, and comorbid ADHD and emotional problems do not reduce effects; maternal depression, rather than being linked to less child change, was associated with greater reductions in children's conduct problems.

Parenting Interventions in Pediatric Primary Care: A Systematic Review

CONTEXT

More than 4 decades of research indicate that parenting interventions are effective at preventing and treating mental, emotional, and behavioral disorders in children and adolescents. Pediatric primary care is a viable setting for delivery of these interventions.

OBJECTIVE

Previous meta-analyses have shown that behavioral interventions in primary care can improve clinical outcomes, but few reviews have been focused specifically on the implementation of parenting interventions in primary care. We aimed to fill this gap.

DATA SOURCES

We reviewed 6532 unique peer-reviewed articles published in PubMed, the Cumulative Index to Nursing and Allied Health Literature, and PsycInfo.

STUDY SELECTION

Articles were included if at least part of the intervention was delivered in or through primary care; parenting was targeted; and child-specific mental, emotional, and behavioral health outcomes were reported.

DATA EXTRACTION

Articles were reviewed in Covidence by 2 trained coders, with a third coder arbitrating discrepancies.

RESULTS

In our review of 40 studies, most studies were coded as a primary. Few researchers collected implementation outcomes, particularly those at the service delivery system level.

LIMITATIONS

Including only published articles could have resulted in underrepresentation of implementation-related data.

CONCLUSIONS

Parenting interventions delivered and implemented with fidelity in pediatric primary care could result in positive and equitable impacts on mental, emotional, and behavioral health outcomes for both parents and their children. Future research on the implementation strategies that can support adoption and sustained delivery of parenting interventions in primary care is needed if the field is to achieve population-level impact.

Equity effects of parenting interventions for child conduct problems: a pan-European individual participant data meta-analysis

BACKGROUND

Childhood conduct problems are a costly public health problem and are five times more common in socially disadvantaged groups than they are in advantaged groups. Untreated, conduct problems have a poor prognosis, with increasing gaps between socioeconomic groups, and high rates of subsequent criminality. Incredible Years is a high quality parenting programme for reducing conduct problems and is widely disseminated in Europe. Many trials have shown Incredible Years to be effective but the potential effects of parenting interventions on social inequality are unknown. Some behavioural interventions (eg, smoking cessation programmes), although beneficial overall, can widen inequality gaps. Because single trials and aggregate-level meta-analyses are ill equipped for examining differential intervention (moderator) effects, we pooled individual-level trial data to assess the effects of Incredible Years on social equity.

METHODS

We did a systematic review and individual participant data meta-analysis by searching CINAHL, Embase, Global Health, Medline, and PsycINFO, for studies published from inception to March 15, 2019. We also searched the Incredible Years website library and consulted with experts, including the European Incredible Years mentors' network. We included data from all completed randomised trials of the Incredible Years parenting intervention in Europe that included children aged 1-12 years, including unpublished trials, without restriction on publication year or outcome measures. We included prevention (selective or universal) and treatment or indicated prevention trials (for children diagnosed or above the clinical cutoff for conduct problems). We excluded trials or conditions within trials that were not randomised, included additional non-parenting material (eg, child-focused interventions), or were abbreviated, non-standard versions of the usual Incredible Years intervention of 12-14 weekly sessions. We requested individual participant data from the study authors. The primary outcome was child conduct problems, assessed using the Eyberg Child Behavior Inventory Intensity (ECBI-I) scale. Moderators were analysed using multilevel modelling with multiple imputation.

FINDINGS

Of 15 European trials of Incredible Years parenting programmes (n=1696 children), individual participant data were unavailable for one trial and one trial did not assess the primary outcome. Children were aged 2-10 years (median 5·1), 492 (30%) of 1651 children were from an ethnic minority and 931 (58%) of 1614 were from low-income families. Families who received the Incredible Years intervention reported an overall reduction in child conduct problems (13·5 points on the ECBI-I scale, 95% CI 10·9-16·1). There were no differential effects by family disadvantage (indicated by poverty, lone parenthood, teenage parenthood, household joblessness, or low education), or ethnic minority status.

INTERPRETATION

We found no evidence for differential effects by social disadvantage, suggesting that Incredible Years is unlikely to widen socioeconomic inequalities in conduct problems. Furthermore, the programme might be an important tool for reducing social disparities and improving poor long-term outcomes in disadvantaged families because follow-up studies indicate that benefits persist. Clinicians and commissioners can be reassured that the programme is similarly effective for families from different backgrounds.

FUNDING

UK National Institute for Health Research.

Evidence-based prevention programs targeting youth mental and behavioral health in primary care: A systematic review

The objectives of this systematic review were to: 1) identify evidence-based youth (i.e., infancy, pre-school age, school age, and adolescence) mental and behavioral health disorder preventive interventions conducted in or offered by primary care settings, and 2) describe these interventions' characteristics, efficacy, and clinical involvement. Randomized controlled trials that targeted the prevention of mental or behavioral health outcomes for youth and had a connection to primary care were included. The PRISMA guidelines were utilized for two phases: 1) searching PubMed, EMBASE, PsycInfo, CINAHL, and Cochrane databases in January 2017; and 2) searching United States Preventive Services Task Force (USPSTF) Systematic Reviews in November 2017. The two phases revealed 504 and 58 potential articles, respectively. After removal of duplicates, screening of abstracts, and full-text reviews, 19 interventions (infancy: n = 2, pre-school age: n = 3, school age: n = 6, adolescence: n = 8) were included: 1) 10 interventions described in 17 articles from the databases, and 2) 9 interventions described in 11 articles from the USPSTF reviews. The included interventions capitalized on primary care settings as a natural entry point to engage youth and families into interventions without requiring a large amount of clinic involvement. Commonalities of efficacious interventions and recommendations for future research are discussed. The authors encourage primary care providers, mental and behavioral health providers, and/or public health researchers to continue developing and testing preventive interventions, or adapting existing interventions, to be implemented in primary care.

Efficacy of a Home Visiting Enhancement for High-Risk Families Attending Parent Management Programs: A Randomized Superiority Clinical Trial

IMPORTANCE

Antisocial behavior and adult criminality often have origins in childhood and are best addressed early in the child's life using evidence-based parenting programs. However, families with additional risk factors do not always make sufficient changes while attending such programs; these families may benefit from additional support.

OBJECTIVE

To evaluate the efficacy of adding a 10-session, structured home parent support (HPS) intervention to enhance outcomes for high-risk families attending the Incredible Years Parent (IYP) program.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical superiority trial of 126 parents of children aged 3 to 7 years with conduct problems compared the IYP program plus HPS with treatment as usual of the IYP program alone. Child behavior measures were collected before and after treatment and at the 6-month follow-up. Recruitment from 19 IYP groups began February 13, 2013, and follow-up data collection was completed June 4, 2015. All data were analyzed using an intention-to-treat design with last observation carried forward. Statistical analysis took place from May 20, 2015, to March 31, 2016.

INTERVENTION

Parents were randomly assigned to receive IYP program plus HPS or IYP alone.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was the posttreatment change in Eyberg Child Behavior Inventory Total Problem Scale (ECBI-P) score. Secondary outcomes included maintenance of change on the ECBI-P score, ECBI Intensity Scale score, and Social Competence Scale score at the 6-month follow-up; percentage of child behavior scores in the clinical range after treatment; retention; and attendance.

RESULTS

A total of 126 parents (112 women and 14 men; mean [SD] age, 34.7 [8.4] years) were included; 63 parents were randomly assigned to each intervention group. Analysis of variance using intention to treat showed no significant difference between groups after treatment (P = .62). At follow-up, there was a medium effect (d = 0.63) showing a significant benefit from IYP plus HPS of 3.6 (95% CI, 0.8-6.5) on the ECBI-P score (F1,124 = 6.3; P = .01). Families receiving the IYP plus HPS intervention had significantly fewer children with child behavior scores in the clinical range after treatment (9 of 51 [17.6%]) compared with families receiving the IYP program alone (18 of 45 [40.0%]), and this status was maintained at follow-up. The HPS intervention had better retention than the IYP program (dropout, 7 [5.6%] vs 16 [12.7%]) as well as better attendance.

CONCLUSIONS AND RELEVANCE

In this trial, the IYP plus HPS intervention significantly improved outcomes for the most vulnerable families at 6 months. This study demonstrated that the HPS intervention is an effective addition to the IYP program to improve engagement and implementation of IYP program strategies and enhance child behavior outcomes for the most vulnerable families.

TRIAL REGISTRATION

http://anzctr.org.au Identifier: ACTRN12612000878875.

The Earlier the Better? Individual Participant Data and Traditional Meta-analysis of Age Effects of Parenting Interventions

Strong arguments have been made for early intervention for child problems, stating that early is more effective than later, as the brain is more malleable, and costs are lower. However, there is scant evidence from trials to support this hypothesis, which we therefore tested in two well-powered, state-of-the-art meta-analyses with complementary strengths: (a) Individual participant data (IPD) meta-analysis of European trials of Incredible Years parenting intervention (k = 13, n = 1696; age = 2-11); (b) Larger, trial-level robust variance estimation meta-analysis of a wider range of parenting programs (k = 156, n = 13,378, M_age  = 2-10) for reducing disruptive behavior. Both analyses found no evidence that intervention earlier in childhood was more effective; programs targeted at a narrower age range were no more effective than general ones.

Preventive Behavioral Health Programs in Primary Care: A Systematic Review

CONTEXT

Early childhood is a critical period for socioemotional development. Primary care is a promising setting for behavioral health programs.

OBJECTIVES

To identify gaps in the literature on effectiveness and readiness for scale-up of behavioral health programs in primary care.

DATA SOURCES

PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Embase, Evidence-Based Medicine Reviews, and Scopus databases were searched for articles published in English in the past 15 years. Search terms included terms to describe intervention content, setting, target population, and names of specific programs known to fit inclusion criteria.

STUDY SELECTION

Inclusion criteria were: (1) enrolled children 0 to 5 years old, (2) primary care setting, (3) measured parenting or child behavior outcomes, and (4) clinical trial, quasi-experimental trial, pilot study, or pre-post design.

DATA EXTRACTION

Data were abstracted from 44 studies. The rigor of individual studies and evidence base as a whole were compared with the Society of Prevention Research's standards for efficacy, effectiveness, and scale-up research.

RESULTS

Gaps in the literature include: study findings do not always support hypotheses about interventions' mechanisms, trust in primary care as a mediator has not been sufficiently studied, it is unclear to which target populations study findings can be applied, parent participation remains an important challenge, and the long-term impact requires further evaluation.

LIMITATIONS

Potential limitations include publication bias, selective reporting within studies, and an incomplete search.

CONCLUSIONS

Targeting gaps in the literature could enhance understanding of the efficacy, effectiveness, and readiness for scale-up of these programs.

Research Review: Harnessing the power of individual participant data in a meta-analysis of the benefits and harms of the Incredible Years parenting program

BACKGROUND

Parenting programs aim to reduce children's conduct problems through improvement of family dynamics. To date, research on the precise benefits and possible harms of parenting programs on family well-being has been unsystematic and likely to be subject to selective outcome reporting and publication bias. Better understanding of program benefits and harms requires full disclosure by researchers of all included measures, and large enough numbers of participants to be able to detect small effects and estimate them precisely.

METHODS

We obtained individual participant data for 14 of 15 randomized controlled trials on the Incredible Years parenting program in Europe (total N = 1,799). We used multilevel modeling to estimate program effects on 13 parent-reported outcomes, including parenting practices, children's mental health, and parental mental health.

RESULTS

Parental use of praise, corporal punishment, threats, and shouting improved, while parental use of tangible rewards, monitoring, or laxness did not. Children's conduct problems and attention deficit hyperactivity disorder (ADHD) symptoms improved, while emotional problems did not. Parental mental health (depressive symptoms, self-efficacy, and stress) did not improve. There was no evidence of harmful effects.

CONCLUSIONS

The Incredible Years parenting program improves the aspects of family well-being that it is primarily designed to improve: parenting and children's conduct problems. It also improves parent-reported ADHD symptoms in children. Wider benefits are limited: the program does not improve children's emotional problems or parental mental health. There are no signs of harm on any of the target outcomes.

Could scale-up of parenting programmes improve child disruptive behaviour and reduce social inequalities? Using individual participant data meta-analysis to establish for whom programmes are effective and cost-effective

Background

Child disruptive behavioural problems are a large and costly public health problem. The Incredible Years®(IY) parenting programme has been disseminated across the UK to prevent this problem and shown to be effective in several trials. It is vital for policy to know for which families IY is most effective, to be sure that it helps reduce, rather than widen, socioeconomic inequalities. Individual trials lack power and generalisability to examine differential effects; conventional meta-analysis lacks information about within-trial variability in effects.

Objectives

To overcome these limitations by pooling individual-level data from the IY parenting trials in Europe to examine to what extent it benefits socially disadvantaged families. Secondary objectives examine (1) additional moderators of effects on child behaviour, (2) wider health benefits and potential harms and (3) costs, cost-effectiveness and potential long-term savings.

Design

Individual participant data meta-analysis of 14 randomised trials of the IY parenting intervention.

Settings

UK (eight trials), the Netherlands, Ireland, Norway, Sweden and Portugal.

Participants

Data were from 1799 families, with children aged 2–10 years (mean 5.1 years; 63% boys).

Interventions

IY Basic parenting programme.

Main outcome measures

Primary outcome was disruptive child behaviour, determined by the Eyberg Child Behavior Inventory Intensity scale (ECBI-I). Secondary outcomes included self-reported parenting practices, parenting stress, mental health, children’s attention deficit hyperactivity disorder (ADHD) and emotional symptoms.

Results

There were no differential effects of IY on disruptive behaviour in families with different levels of social/socioeconomic disadvantage or differential effects for ethnic minority families, families with different parenting styles, or for children with comorbid ADHD or emotional problems or of different ages. Some moderators were found: intervention effects were strongest in children with more severe baseline disruptive behaviour, in boys, and in children with parents who were more depressed. Wider health benefits included reduced child ADHD symptoms, greater parental use of praise, and reduced harsh and inconsistent discipline. The intervention did not improve parental depression, stress, self-efficacy or children’s emotional problems. Economic data were available for five UK and Ireland trials (maximumn = 608). The average cost per person of the IY intervention was £2414. The probability that the IY intervention is considered cost-effective is 99% at a willingness to pay of £145 per 1-point improvement on the ECBI-I. Estimated longer-term savings over 20 years range from £1000 to £8400 per child, probably offsetting the cost of the intervention.

Limitations

Limitations include a focus on one parenting programme; the need to make assumptions in harmonising data; and the fact that data addressed equalities in the effectiveness of, not access to, the intervention.

Conclusions

There is no evidence that the benefits of the IY parenting intervention are reduced in disadvantaged or minority families; benefits are greater in the most distressed families, including parents who are depressed. Thus, the intervention is unlikely to widen socioeconomic inequalities in disruptive behaviour and may have effects in narrowing inequalities due to parent depression. It was as likely to be effective for older as for younger children. It has wider benefits for ADHD and parenting and is likely to be considered to be cost-effective. Researchers/funders should encourage data sharing to test equity and other moderator questions for other interventions; further research is needed on enhancing equality of access to interventions.

Funding

The National Institute for Health Research Public Health Research programme.

Clinical Effectiveness of Family Therapeutic Interventions Embedded in General Pediatric Primary Care Settings for Parental Mental Health: A Systematic Review and Meta-analysis

The aim of this systematic review and meta-analysis was to synthesize the available evidence on embedded family therapy interventions in pediatrics and impacts on parental mental health and family functioning outcomes. The Cochrane Collaboration guidelines for systematic reviews and meta-analysis were used for this study. Six electronic databases were searched for randomized controlled trials and cluster randomized trials. The Cochrane Collaboration's Risk of Bias Tool and GRADE system were used to rate the quality of evidence of the included studies. The primary outcomes included parental distress, parental depressive symptoms, and dysfunctional parent-child interaction. Fixed effects models showed statistically significant reductions in parental distress at 6-month and 12-month post-intervention in favor of the intervention group. Family therapy model, intervention level, delivery modality, and dosage moderated intervention impacts on parental distress. Fixed effects models showed statistically significant reductions in parental depressive symptoms and in dysfunctional parent-child interaction in favor of the intervention group. Family therapy interventions can be successfully embedded in general pediatric primary care, and intended outcomes are achieved in this setting. Recommendations for future research and implications for policy development are discussed.

Addressing Parental Mental Health Within Interventions for Children: A Review

PURPOSE

Untreated parent mental health problems have deleterious effects upon the family, yet caregivers are unlikely to receive services for their emotional health. We conducted a review of treatments and services for children and adolescents that also offered services to parents.

METHODS

Child treatment and service studies were included in the present study if they analyzed parent symptoms or diagnoses over time, and the intervention contained a parent component.

RESULTS

Of 200 studies reviewed, 20 contained a component for the parent and assessed the parent's emotional health at multiple time points. Depression and anxiety were the most commonly studied parental mental health problem; most parent components consisted of behavioral strategies in service of the child's psychological health.

CONCLUSION

Major shifts in health care policy affecting mental health services provide an opportunity to create integrated and coordinated health and behavioral health systems. Attention must be given to ensure that the workforce of providers, the administrative structures, and the reimbursement strategies are strengthened and connected to serve the needs of parents/caregivers and children in order to enhance family outcomes.

Is there a case for mental health promotion in the primary care setting? A systematic review

OBJECTIVES

To evaluate the effectiveness of mental health promotion (MHP) interventions by primary health care professionals in the adult population.

METHODS

Systematic review of literature in English and Spanish for randomized controlled trials (RCTs) and observational studies evaluating the impact of interventions carried out by primary care professionals explicitly to promote and improve the overall mental health of adult patients. PubMed, PsycINFO, and Web of Science were independently searched by two investigators to identify all MHP articles from inception to October 2013 (no restrictions).

RESULTS

We retrieved 4262 records and excluded 4230 by a review of title and abstract. Of 32 full-text articles assessed, 3 RCTs were selected (2 in USA, 1 in UK); two focused on the mental health of parents whose children have behavioral problems, the other on older people with disabilities. One study reported a MHP intervention that improved participants' mental health at 6-month follow-up. All studies had low-moderate quality (2 of 5 points) on the Jadad Scale.

CONCLUSION

There is a lack of implementation and/or evaluation of mental health promotion activities conducted by primary care professionals. More research is needed to clearly understand the benefits of promoting mental health in this setting.

Programs for Prevention of Externalizing Problems in Children: Limited Evidence for Effect Beyond 6 Months Post Intervention

Background

Preventing externalizing problems in children is a major societal concern, and a great number of intervention programs have been developed to this aim. To evaluate their preventive effects, well-controlled trials including follow-up assessments are necessary.

Methods

This is a systematic review of the effect of prevention programs targeting externalizing problems in children. The review covered peer reviewed publications in English, German, French, Spanish and Scandinavian languages. Experimental studies of standardized programs explicitly aiming at preventing externalizing mental ill-health in children (2–19 years), with outcome assessments at ≥6 months post intervention for both intervention and control groups, were included. We also included long-term trials with consecutive observations over several years, even in the absence of follow-up ≥6 months post intervention. Studies of clinical populations or children with impairments, which substantially increase the risk for mental disorders, were excluded.

Results

Thirty-eight controlled trials assessing 25 different programs met inclusion criteria. Only five programs were supported by scientific evidence, representing selective parent training (Incredible Years and Triple-P), indicated family support (Family Check-Up), and school-based programs (Good Behavior Game, universally delivered, and Coping Power, as an indicated intervention). With few exceptions, effects after 6–12 months were small. Long-term trials showed small and inconsistent effects.

Conclusions

Despite a vast literature, the evidence for preventive effects is meager, largely due to insufficient follow-up post intervention. Long-term follow up assessment and effectiveness studies should be given priority in future evaluations of interventions to prevent externalizing problems in children.

Developing a model of mental health self-care support for children and young people through an integrated evaluation of available types of provision involving systematic review, meta-analysis and case study

Background

The mental health of children and young people (CYP) is a major UK public health concern. Recent policy reviews have identified that service provision for CYP with mental health needs is not as effective, responsive, accessible or child-centred as it could be. Following on from a previous National Institute for Health Research (NIHR) study into self-care support for CYP with long-term physical health needs, this study explored self-care support’s potential in CYP’s mental health.

Objectives

To identify and evaluate the types of mental health self-care support used by, and available to, CYP and their parents, and to establish how such support interfaces with statutory and non-statutory service provision.

Design

Two inter-related systematic literature reviews (an effectiveness review with meta-analysis and a perceptions review), together with a service mapping exercise and case study.

Setting

Global (systematic reviews); England and Wales (mapping exercise and case study).

Participants (case study)

Fifty-two individuals (17 CYP, 16 family members and 19 staff) were interviewed across six sites.

Main outcome measures (meta-analysis)

A measure of CYP’s mental health symptomatology.

Data sources (literature reviews)

MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, All Evidence-Based Medicine (EBM) Reviews, Applied Social Sciences Index and Abstracts (ASSIA) and Education Resources Information Center (ERIC).

Review methods

Titles and abstracts of papers were screened for relevance then grouped into studies. Two independent reviewers extracted data from studies meeting the inclusion criteria. A descriptive analysis and meta-analysis were conducted for the effectiveness review; descriptive analyses were conducted for the perceptions review. These analyses were integrated to elicit a mixed-methods review.

Results

Sixty-five of 71 included studies were meta-analysable. These 65 studies elicited 71 comparisons which, when meta-analysed, suggested that self-care support interventions were effective at 6-month [standardised mean difference (SMD) = −0.20; 95% confidence interval (CI) −0.28 to −0.11] and 12-month (SMD = −0.12; 95% CI −0.17 to −0.06) follow-ups. However, judged against Cochrane criteria, the studies were mostly low quality. Key elements of self-care support identified in the perceptions review were the acquisition of knowledge and skills, peer support and the relationship with the self-care support agent; CYP also had different perceptions from adults about what is important in self-care support. The mapping exercise identified 27 providers of 33 self-care support services. According to the case study data, effective self-care support services are predicated on flexibility; straightforward access; non-judgemental, welcoming organisations and staff; the provision of time and attention; opportunities to learn and practise skills relevant to self-care; and systems of peer support.

Conclusions

Mental health self-care support interventions for CYP are modestly effective in the short to medium term. Self-care support can be conceptualised as a process which has overlap with ‘recovery’. CYP and their families want choice and flexibility in the provision of such interventions and a continued relationship with services after the nominal therapy period. Those delivering self-care support need to have specific child-centred attributes.

Future work

Future work should focus on under-represented conditions (e.g. psychosis, eating disorders, self-harm); the role of technology, leadership and readiness in self-care support; satisfaction in self-care support; the conceptualisation of self-care support in CYP’s mental health; and efficacy and cost-effectiveness.

Study registration

PROSPERO number (for the effectiveness review) CRD42012001981.

Funding

The NIHR Health Services and Delivery Research programme.

Group-based parent training programmes for improving parental psychosocial health

BACKGROUND

Parental psychosocial health can have a significant effect on the parent-child relationship, with consequences for the later psychological health of the child. Parenting programmes have been shown to have an impact on the emotional and behavioural adjustment of children, but there have been no reviews to date of their impact on parental psychosocial wellbeing.

OBJECTIVES

To address whether group-based parenting programmes are effective in improving parental psychosocial wellbeing (for example, anxiety, depression, guilt, confidence).

SEARCH METHODS

We searched the following databases on 5 December 2011: CENTRAL (2011, Issue 4), MEDLINE (1950 to November 2011), EMBASE (1980 to week 48, 2011), BIOSIS (1970 to 2 December 2011), CINAHL (1982 to November 2011), PsycINFO (1970 to November week 5, 2011), ERIC (1966 to November 2011), Sociological Abstracts (1952 to November 2011), Social Science Citation Index (1970 to 2 December 2011), metaRegister of Controlled Trials (5 December 2011), NSPCC Library (5 December 2011). We searched ASSIA (1980 to current) on 10 November 2012 and the National Research Register was last searched in 2005.

SELECTION CRITERIA

We included randomised controlled trials that compared a group-based parenting programme with a control condition and used at least one standardised measure of parental psychosocial health. Control conditions could be waiting-list, no treatment, treatment as usual or a placebo.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data independently and assessed the risk of bias in each study. We examined the studies for any information on adverse effects. We contacted authors where information was missing from trial reports. We standardised the treatment effect for each outcome in each study by dividing the mean difference in post-intervention scores between the intervention and control groups by the pooled standard deviation.

MAIN RESULTS

We included 48 studies that involved 4937 participants and covered three types of programme: behavioural, cognitive-behavioural and multimodal. Overall, we found that group-based parenting programmes led to statistically significant short-term improvements in depression (standardised mean difference (SMD) -0.17, 95% confidence interval (CI) -0.28 to -0.07), anxiety (SMD -0.22, 95% CI -0.43 to -0.01), stress (SMD -0.29, 95% CI -0.42 to -0.15), anger (SMD -0.60, 95% CI -1.00 to -0.20), guilt (SMD -0.79, 95% CI -1.18 to -0.41), confidence (SMD -0.34, 95% CI -0.51 to -0.17) and satisfaction with the partner relationship (SMD -0.28, 95% CI -0.47 to -0.09). However, only stress and confidence continued to be statistically significant at six month follow-up, and none were significant at one year. There was no evidence of any effect on self-esteem (SMD -0.01, 95% CI -0.45 to 0.42). None of the trials reported on aggression or adverse effects.The limited data that explicitly focused on outcomes for fathers showed a statistically significant short-term improvement in paternal stress (SMD -0.43, 95% CI -0.79 to -0.06). We were unable to combine data for other outcomes and individual study results were inconclusive in terms of any effect on depressive symptoms, confidence or partner satisfaction.

AUTHORS' CONCLUSIONS

The findings of this review support the use of parenting programmes to improve the short-term psychosocial wellbeing of parents. Further input may be required to ensure that these results are maintained. More research is needed that explicitly addresses the benefits for fathers, and that examines the comparative effectiveness of different types of programme along with the mechanisms by which such programmes bring about improvements in parental psychosocial functioning.

Do evidence-based interventions work when tested in the "real world?" A systematic review and meta-analysis of parent management training for the treatment of child disruptive behavior

Evidence-based interventions are often unavailable in everyday clinical settings. This may partly reflect practitioners' assumptions that research evidence does not reflect "real-world" conditions. To examine this further, we systematically assessed the clinical effectiveness of parent management training (PMT) for the treatment of child disruptive behavior across different real-world practice contexts. We identified 28 relevant randomized controlled trials from a systematic search of electronic bibliographic databases and conducted a meta-analysis of child outcomes across trials. Planned subgroup analyses involved comparisons between studies grouped according to individual real-world practice criteria and total real-world practice criteria scores, reflecting the extent to which PMT was delivered by non-specialist therapists, to a clinic-referred population, in a routine setting, and as part of a routine service. Meta-analysis revealed a significant overall advantage for PMT compared with waitlist control conditions. Subgroup analyses did not demonstrate significant differences in effect size estimates according to the total number of real-world practice criteria met by studies. Moreover, no consistent relationships were found between specific practice criteria and effect size estimates. In conclusion, PMT appears to be an effective treatment for children with disruptive behavior problems. There was no clear evidence that conducting PMT in real-world practice contexts is a deterrent to achieving effective child behavior outcomes, although relative advantage to "usual care" was not directly examined and the power of the analysis was limited as a result of significant heterogeneity. More research is needed to investigate whether this finding is generalizable to other psychological interventions. Suggestions are also made for developing more differentiated criteria to assist with evaluating the specific applicability of research evidence to different care providers.

Cochrane review: behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years (Review)

BACKGROUND

Early-onset child conduct problems are common and costly. A large number of studies and some previous reviews have focused on behavioural and cognitive-behavioural group-based parenting interventions, but methodological limitations are commonplace and evidence for the effectiveness and cost-effectiveness of these programmes has been unclear.

OBJECTIVES

To assess the effectiveness and cost-effectiveness of behavioural and cognitive-behavioural group-based parenting programmes for improving child conduct problems, parental mental health and parenting skills.

SEARCH METHODS

We searched the following databases between 23 and 31 January 2011: CENTRAL (2011, Issue 1), MEDLINE (1950 to current), EMBASE (1980 to current), CINAHL (1982 to current), PsycINFO (1872 to current), Social Science Citation Index (1956 to current), ASSIA (1987 to current), ERIC (1966 to current), Sociological Abstracts (1963 to current), Academic Search Premier (1970 to current), Econlit (1969 to current), PEDE (1980 to current), Dissertations and Theses Abstracts (1980 to present), NHS EED (searched 31 January 2011), HEED (searched 31 January 2011), DARE (searched 31 January 2011), HTA (searched 31 January 2011), mRCT (searched 29 January 2011). We searched the following parent training websites on 31 January 2011: Triple P Library, Incredible Years Library and Parent Management Training. We also searched the reference lists of studies and reviews.

SELECTION CRITERIA

We included studies if: (1) they involved randomised controlled trials (RCTs) or quasi-randomised controlled trials of behavioural and cognitive-behavioural group-based parenting interventions for parents of children aged 3 to 12 years with conduct problems, and (2) incorporated an intervention group versus a waiting list, no treatment or standard treatment control group. We only included studies that used at least one standardised instrument to measure child conduct problems.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias in the trials and the methodological quality of health economic studies. Two authors also independently extracted data. We contacted study authors for additional information.

MAIN RESULTS

This review includes 13 trials (10 RCTs and three quasi-randomised trials), as well as two economic evaluations based on two of the trials. Overall, there were 1078 participants (646 in the intervention group; 432 in the control group). The results indicate that parent training produced a statistically significant reduction in child conduct problems, whether assessed by parents (standardised mean difference (SMD) -0.53; 95% confidence interval (CI) -0.72 to -0.34) or independently assessed (SMD -0.44; 95% CI -0.77 to -0.11). The intervention led to statistically significant improvements in parental mental health (SMD -0.36; 95% CI -0.52 to -0.20) and positive parenting skills, based on both parent reports (SMD -0.53; 95% CI -0.90 to -0.16) and independent reports (SMD -0.47; 95% CI -0.65 to -0.29). Parent training also produced a statistically significant reduction in negative or harsh parenting practices according to both parent reports (SMD -0.77; 95% CI -0.96 to -0.59) and independent assessments (SMD -0.42; 95% CI -0.67 to -0.16). Moreover, the intervention demonstrated evidence of cost-effectiveness. When compared to a waiting list control group, there was a cost of approximately $2500 (GBP 1712; EUR 2217) per family to bring the average child with clinical levels of conduct problems into the non-clinical range. These costs of programme delivery are modest when compared with the long-term health, social, educational and legal costs associated with childhood conduct problems.

AUTHORS' CONCLUSIONS

Behavioural and cognitive-behavioural group-based parenting interventions are effective and cost-effective for improving child conduct problems, parental mental health and parenting skills in the short term. The cost of programme delivery was modest when compared with the long-term health, social, educational and legal costs associated with childhood conduct problems. Further research is needed on the long-term assessment of outcomes.

Does socioeconomic status matter? A meta-analysis on parent training effectiveness for disruptive child behavior

Disadvantaged family socioeconomic status (SES) is often assumed to diminish parent training program effectiveness. In examining effects of SES, influences of initial problem severity have been largely ignored. In the present meta-analysis, we examined (a) whether there is a differential influence of SES on parent training effectiveness at immediate posttreatment and at 1-year follow-up-controlling for levels of initial problem severity--and (b) whether SES interacts with initial problem severity in its effect on program effectiveness. Seventy-five studies on parent training program effectiveness to reduce disruptive child behavior were included. Separate analyses were conducted for immediate posttreatment and approximately 1-year follow-up assessments. Immediately posttreatment, disadvantaged samples benefited less from parent training, but only when they had low levels of initial problem severity. At follow-up, disadvantaged samples benefited less from parent training regardless of initial problem severity. Initial problem severity was a strong predictor of effect sizes both immediately posttreatment and at follow-up. Parent training programs are equally effective for disadvantaged and nondisadvantaged families immediately posttreatment, at least when initial problems are severe. Maintenance of treatment gain, however, seems harder for disadvantaged families, suggesting that more sustained family support may be needed.

An analysis of two evidence-based parent training programmes and determination of the characteristics for a new programme model

The Triple P and Incredible Years are the two best (well-known) parent programmes which cooperate with families and the society, reduce the risk factors and support the protective factors. The programmes also offer a multidisciplinary approach with high evidence standards, use randomized controlled studies and yield long-term results. Accordingly, this literature review was conducted in order to evaluate the efficacy of these two programmes, to determine the (similarities) and differences. 'MEDLINE, PUBMED, COCHRANE' databases, online and published journals and dissertations in Turkey were reviewed for the study. Consequently, results of 49 studies were presented, which were evaluated according to certain criteria such as samples, methods and results. The studies on the Triple P and the Incredible Years Parent Program illustrated a decrease in problematic behaviours of the children and negative parenting practices of parents following the implementation of programmes. However, the studies also pointed out the differences between the Triple P and the Incredible Years Parent Program. It is recommended that a new parent education programme be prepared and tested for our country in accordance with the results of the study.

A cost-effectiveness analysis of the Incredible Years parenting programme in reducing childhood health inequalities

Early onset of behavioural problems has lasting negative effects on a broad range of lifetime outcomes, placing large costs on individuals, families and society. A number of researchers and policy makers have argued that early interventions aimed at supporting the family is the most effective way of tackling child behaviour problems. This study forms the economic component of a randomised evaluation of the Incredible Years programme, a programme aimed at improving the skills and parenting strategies of parents of children with conduct problems. Our results show that the programme provides a cost-effective way of reducing behavioural problems. Furthermore, our cost analysis, when combined with a consideration of the potential long-run benefits, suggests that investment in such programmes may generate favourable long-run economic returns.

Randomized trial of distance-based treatment for young children with discipline problems seen in primary health care

OBJECTIVE

Many parents of preschool-age children have concerns about how to discipline their child but few receive help. We examined the effects of a brief treatment along with usual care, compared with receiving usual care alone. Patients. Parents (N = 178) with concerns about their 2- to 5-year olds' discipline were recruited when they visited their family physician at 1 of 24 practices.

METHODS

After completing mailed baseline measures, parents were randomly assigned to receive usual care or the Parenting Matters intervention along with usual care. Parenting Matters combined a self-help booklet with two calls from a telephone coach during a 6-week treatment period. Follow-up assessments were completed at 7 weeks post-randomization, and 3 and 6 months later.

RESULTS

Behaviour problems (Eyberg Child Behaviour Inventory) decreased significantly more in the Parenting Matters condition compared with Usual Care alone, based on a significant time by treatment group effect in intent-to-treat, growth curve analyses (P = 0.033). The Parenting Matters group also demonstrated greater and more rapid improvement than in usual care alone in terms of overall psychopathology (Child Behaviour Checklist, P = 0.02), but there were no group differences in parenting. The overall magnitude of group differences was small (d = 0.15 or less).

CONCLUSION

A brief early intervention combining a self-help booklet and telephone coaching is an effective way to treat mild behaviour problems among young children. This minimal-contact approach addresses the need for interventions in primary health care settings and may be a useful component in step-care models of mental health.

Outcome domains in child mental health research since 1996: have they changed and why does it matter?

OBJECTIVE

Child mental health treatment and services research yields more immediate public health benefit when they focus on outcomes of relevance to a broader group of stakeholders. We reviewed all experimental studies of child and adolescent treatment and service effectiveness published in the last 15 years (1996-2011) and compared the distribution and types of outcome domains to a prior review that focused on studies from the prior 15 years (1980-1995).

METHOD

Studies were included if they focused on children from birth to 18 years of age with specific or general psychiatric conditions, employed randomized designs, and examined intervention effects with a six-month or longer post-treatment assessment in treatment studies or a 6-month or longer post-baseline assessment for services studies. Two hundred (n=200) studies met criteria. Reported outcome measures were coded into conceptual categories drawn from the 1980-1995 review.

RESULTS

There was a five-fold increase in the total number of studies (38 versus 200) across the two 15-year time periods, with the largest increase in the number of studies that focused on consumer-oriented outcomes (from eight to 47 studies, an almost sixfold increase); two new domains, parent symptoms and health-related outcomes, were identified. The majority of studies (more than 95%) continued to focus on symptoms and diagnoses as an outcome. Impact ratings were higher among studies examining four or more outcomes versus one to two outcomes in all categories with the exception of Posttraumatic Stress Disorder.

CONCLUSIONS

Given major shifts in health care policy affecting mental health services, the emergence of health and parent-related outcomes as well as greater attention to consumer perspectives parallels emerging priorities in health care and can enhance the relevance of child outcome studies for implementation in the real world.

Designing a physical activity parenting course: parental views on recruitment, content and delivery

Background

Many children do not engage in sufficient levels of physical activity (PA) and spend too much time screen-viewing (SV). High levels of SV (e.g. watching TV, playing video games and surfing the internet) and low levels of PA have been associated with adverse health outcomes. Parenting courses may hold promise as an intervention medium to change children’s PA and SV. The current study was formative work conducted to design a new parenting programme to increase children’s PA and reduce their SV. Specifically, we focussed on interest in a course, desired content and delivery style, barriers and facilitators to participation and opinions on control group provision.

Methods

In-depth telephone interviews were conducted with thirty two parents (29 female) of 6–8 year olds. Data were analysed thematically. An anonymous online survey was also completed by 750 parents of 6–8 year old children and descriptive statistics calculated.

Results

Interview participants were interested in a parenting course because they wanted general parenting advice and ideas to help their children be physically active. Parents indicated that they would benefit from knowing how to quantify their child’s PA and SV levels. Parents wanted practical ideas of alternatives to SV. Most parents would be unable to attend unless childcare was provided. Schools were perceived to be a trusted source of information about parenting courses and the optimal recruitment location. In terms of delivery style, the majority of parents stated they would prefer a group-based approach that provided opportunities for peer learning and support with professional input. Survey participants reported the timing of classes and the provision of childcare were essential factors that would affect participation. In terms of designing an intervention, the most preferred control group option was the opportunity to attend the same course at a later date.

Conclusions

Parents are interested in PA/SV parenting courses but the provision of child care is essential for attendance. Recruitment is likely to be facilitated via trusted sources. Parents want practical advice on how to overcome barriers and suggest advice is provided in a mutually supportive group experience with expert input.

Sustained effects of incredible years as a preventive intervention in preschool children with conduct problems

The present study evaluated preventive effects of the Incredible Years program for parents of preschool children who were at risk for a chronic pattern of conduct problems, in the Netherlands. In a matched control design, 72 parents of children with conduct problems received the Incredible Years program. These families (intervention group) were compared with 72 families who received care as usual (control group). Two years after termination of the intervention, it appeared that observed and selfrated parenting skills were significantly improved in the intervention group. Likewise, in this group, observed child conduct problems showed sustained intervention effects. The decrease in observed critical parenting mediated the decrease in observed child conduct problems over time. In addition, it appeared that parental influence increased over time.

Group-based parent training programmes for improving parental psychosocial health

BACKGROUND

Parental psychosocial health can have a significant effect on the parent-child relationship, with consequences for the later psychological health of the child. Parenting programmes have been shown to have an impact on the emotional and behavioural adjustment of children, but there have been no reviews to date of their impact on parental psychosocial wellbeing.

OBJECTIVES

To address whether group-based parenting programmes are effective in improving parental psychosocial wellbeing (for example, anxiety, depression, guilt, confidence).

SEARCH METHODS

We searched the following databases on 5 December 2012: CENTRAL (2011, Issue 4), MEDLINE (1950 to November 2011), EMBASE (1980 to week 48, 2011), BIOSIS (1970 to 2 December 2011), CINAHL (1982 to November 2011), PsycINFO (1970 to November week 5, 2011), ERIC (1966 to November 2011), Sociological Abstracts (1952 to November 2011), Social Science Citation Index (1970 to 2 December 2011), metaRegister of Controlled Trials (5 December 2011), NSPCC Library (5 December 2011). We searched ASSIA (1980 to current) on 10 November 2012 and the National Research Register was last searched in 2005.

SELECTION CRITERIA

We included randomised controlled trials that compared a group-based parenting programme with a control condition and used at least one standardised measure of parental psychosocial health. Control conditions could be waiting-list, no treatment, treatment as usual or a placebo.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data independently and assessed the risk of bias in each study. We examined the studies for any information on adverse effects. We contacted authors where information was missing from trial reports. We standardised the treatment effect for each outcome in each study by dividing the mean difference in post-intervention scores between the intervention and control groups by the pooled standard deviation.

MAIN RESULTS

We included 48 studies that involved 4937 participants and covered three types of programme: behavioural, cognitive-behavioural and multimodal. Overall, we found that group-based parenting programmes led to statistically significant short-term improvements in depression (standardised mean difference (SMD) -0.17, 95% confidence interval (CI) -0.28 to -0.07), anxiety (SMD -0.22, 95% CI -0.43 to -0.01), stress (SMD -0.29, 95% CI -0.42 to -0.15), anger (SMD -0.60, 95% CI -1.00 to -0.20), guilt (SMD -0.79, 95% CI -1.18 to -0.41), confidence (SMD -0.34, 95% CI -0.51 to -0.17) and satisfaction with the partner relationship (SMD -0.28, 95% CI -0.47 to -0.09). However, only stress and confidence continued to be statistically significant at six month follow-up, and none were significant at one year. There was no evidence of any effect on self-esteem (SMD -0.01, 95% CI -0.45 to 0.42). None of the trials reported on aggression or adverse effects.The limited data that explicitly focused on outcomes for fathers showed a statistically significant short-term improvement in paternal stress (SMD -0.43, 95% CI -0.79 to -0.06). We were unable to combine data for other outcomes and individual study results were inconclusive in terms of any effect on depressive symptoms, confidence or partner satisfaction.

AUTHORS' CONCLUSIONS

The findings of this review support the use of parenting programmes to improve the short-term psychosocial wellbeing of parents. Further input may be required to ensure that these results are maintained. More research is needed that explicitly addresses the benefits for fathers, and that examines the comparative effectiveness of different types of programme along with the mechanisms by which such programmes bring about improvements in parental psychosocial functioning.

Behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years

BACKGROUND

Early-onset child conduct problems are common and costly. A large number of studies and some previous reviews have focused on behavioural and cognitive-behavioural group-based parenting interventions, but methodological limitations are commonplace and evidence for the effectiveness and cost-effectiveness of these programmes has been unclear.

OBJECTIVES

To assess the effectiveness and cost-effectiveness of behavioural and cognitive-behavioural group-based parenting programmes for improving child conduct problems, parental mental health and parenting skills.

SEARCH METHODS

We searched the following databases between 23 and 31 January 2011: CENTRAL (2011, Issue 1), MEDLINE (1950 to current), EMBASE (1980 to current), CINAHL (1982 to current), PsycINFO (1872 to current), Social Science Citation Index (1956 to current), ASSIA (1987 to current), ERIC (1966 to current), Sociological Abstracts (1963 to current), Academic Search Premier (1970 to current), Econlit (1969 to current), PEDE (1980 to current), Dissertations and Theses Abstracts (1980 to present), NHS EED (searched 31 January 2011), HEED (searched 31 January 2011), DARE (searched 31 January 2011), HTA (searched 31 January 2011), mRCT (searched 29 January 2011). We searched the following parent training websites on 31 January 2011: Triple P Library, Incredible Years Library and Parent Management Training. We also searched the reference lists of studies and reviews.

SELECTION CRITERIA

We included studies if: (1) they involved randomised controlled trials (RCTs) or quasi-randomised controlled trials of behavioural and cognitive-behavioural group-based parenting interventions for parents of children aged 3 to 12 years with conduct problems, and (2) incorporated an intervention group versus a waiting list, no treatment or standard treatment control group. We only included studies that used at least one standardised instrument to measure child conduct problems.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias in the trials and the methodological quality of health economic studies. Two authors also independently extracted data. We contacted study authors for additional information.

MAIN RESULTS

This review includes 13 trials (10 RCTs and three quasi-randomised trials), as well as two economic evaluations based on two of the trials. Overall, there were 1078 participants (646 in the intervention group; 432 in the control group). The results indicate that parent training produced a statistically significant reduction in child conduct problems, whether assessed by parents (standardised mean difference (SMD) -0.53; 95% confidence interval (CI) -0.72 to -0.34) or independently assessed (SMD -0.44; 95% CI -0.77 to -0.11). The intervention led to statistically significant improvements in parental mental health (SMD -0.36; 95% CI -0.52 to -0.20) and positive parenting skills, based on both parent reports (SMD -0.53; 95% CI -0.90 to -0.16) and independent reports (SMD -0.47; 95% CI -0.65 to -0.29). Parent training also produced a statistically significant reduction in negative or harsh parenting practices according to both parent reports (SMD -0.77; 95% CI -0.96 to -0.59) and independent assessments (SMD -0.42; 95% CI -0.67 to -0.16). Moreover, the intervention demonstrated evidence of cost-effectiveness. When compared to a waiting list control group, there was a cost of approximately $2500 (GBP 1712; EUR 2217) per family to bring the average child with clinical levels of conduct problems into the non-clinical range. These costs of programme delivery are modest when compared with the long-term health, social, educational and legal costs associated with childhood conduct problems.

AUTHORS' CONCLUSIONS

Behavioural and cognitive-behavioural group-based parenting interventions are effective and cost-effective for improving child conduct problems, parental mental health and parenting skills in the short term. The cost of programme delivery was modest when compared with the long-term health, social, educational and legal costs associated with childhood conduct problems. Further research is needed on the long-term assessment of outcomes.

Effective intervention programming: improving maternal adjustment through parent education

This study assessed the secondary effects of a parent training intervention program on maternal adjustment, with a focus on understanding ways in which program efficacy differed for participants as a function of whether or not their children had behavior problems. Mothers (N = 99) of toddlers (2-3 years of age) were randomly assigned to receive one of three levels of intervention: (1) informational booklet (2) booklet + face-to-face parent training sessions, or (3) booklet + web-based parent training sessions. Findings indicated that all levels of intervention were associated with increases in maternal well-being for participants with typically developing children. Mothers of toddlers with behavior problems, however, did not benefit from receiving only the booklet but significantly benefitted from receiving either the face-to-face or web-based interventions. Findings are discussed in terms of efficient and efficacious program dissemination and the resulting implications for public policy.

Predicting intention to attend and actual attendance at a universal parent-training programme: a comparison of social cognition models

The predictive validity of the Health Belief Model (HBM) and the Theory of Planned Behaviour (TPB) were examined in relation to 'intention to attend' and 'actual attendance' at a universal parent-training intervention for parents of children with behavioural difficulties. A validation and reliability study was conducted to develop two questionnaires (N = 108 parents of children aged 4-7).These questionnaires were then used to investigate the predictive validity of the two models in relation to 'intention to attend' and 'actual attendance' at a parent-training intervention ( N = 53 parents of children aged 4-7). Both models significantly predicted 'intention to attend a parent-training group'; however, the TPB accounted for more variance in the outcome variable compared to the HBM. Preliminary investigations highlighted that attendees were more likely to intend to attend the groups, have positive attitudes towards the groups, perceive important others as having positive attitudes towards the groups, and report elevated child problem behaviour scores. These findings provide useful information regarding the belief-based factors that affect attendance at universal parent-training groups. Possible interventions aimed at increasing 'intention to attend' and 'actual attendance' at parent-training groups are discussed.

A rapid review of key strategies to improve the cognitive and social development of children in Scotland

OBJECTIVES

Inequalities in health and educational outcomes in Scotland show a strong and persistent socioeconomic status gradient. Our aims were to provide policy-makers with a synthesis of international research evidence that assesses the effectiveness of early childhood interventions aimed at equitably promoting cognitive and social development and suggest potential areas for action in Scotland.

METHODS

A rapid review was conducted of review level studies of early childhood interventions with outcome measures relating to child cognitive-language or social-emotional development, subsequent academic and life achievement. Websites were searched and interviews were conducted to identify relevant interventions, policies and programmes delivered in Scotland.

RESULTS

: Early childhood intervention programmes can reduce disadvantage due to social and environmental factors. Scottish health policy demonstrates a clear commitment to early childhood development but much work remains in terms of detail of policy implementation, identification of high risk children and families, and early childhood monitoring systems.

CONCLUSIONS

Programmes should provide a universal seamless continuum of care and support from pregnancy through to school entry with the intensity of support graded according to need. The current information systems in Scotland would be inadequate for monitoring the effects of early childhood interventions especially in relation to cognitive-language and social-emotional development.

Systematic review of preventive interventions for children's mental health: what would work in Australian contexts?

In childhood, mental health problems primarily consist of behaviour and emotional problems. These affect one in every seven children (i.e. 200 000 in Australia). Left untreated, up to 50% of preschool problems continue through the childhood years. Because of their high prevalence, population-based approaches will be needed to reduce their associated burden. The aim of the present study was therefore to identify evidence-based preventive interventions for behavioural and emotional problems of children aged 0-8 years. Randomized controlled trials of preventive interventions for behavioural and emotional problems were located by searching standard clinical databases and systematic reviews. The authors determined which programmes were effective and ineffective, dividing the effective programmes into those with high or low risk of trial bias. Among effective programmes, the most promising for delivery in Australian contexts were identified, selected for their strength of evidence, sample comparability to Australia's population, and programme compatibility with Australia's service system. Around 50 preventive interventions have been evaluated in randomized controlled trials. Most targeted children's behavioural problems, and a few targeted emotional problems. Three US programmes have the best balance of evidence: in infancy, the individual Nurse Home Visitation Programme; at preschool age, the individual Family Check Up; at school age, the Good Behaviour Game class programme. Three parenting programmes in England and Australia are also worthy of highlight: the Incredible Years group format, Triple P individual format, and Parent Education Programme group format. Effective preventive interventions exist primarily for behaviour and, to a lesser extent, emotional problems, and could be disseminated from research to mainstream in Australia, ensuring fidelity to original programmes. Future research should develop programmes targeting emotional problems, and replicate effective programmes for behaviour problems in quality population translation trials. Randomized trial methods in staged roll-outs can determine population cost-benefits for children's mental health without delaying dissemination.

Confirmatory Factor Analysis of the Adolescent Self-Report Strengths and Difficulties Questionnaire

Abstract. The Strengths and Difficulties Questionnaire (SDQ) is a widely used 25-item screening test for emotional and behavioral problems in children and adolescents. This study attempted to critically examine the factor structure of the adolescent self-report version. As part of an ongoing longitudinal cohort study, a total of 3,753 pupils completed the SDQ when aged 12. Both three- and five-factor exploratory factor analysis models were estimated. A number of deviations from the hypothesized SDQ structure were observed, including a lack of unidimensionality within particular subscales, cross-loadings, and items failing to load on any factor. Model fit of the confirmatory factor analysis model was modest, providing limited support for the hypothesized five-component structure. The analyses suggested a number of weaknesses within the component structure of the self-report SDQ, particularly in relation to the reverse-coded items.

The applicability of Webster-Stratton Parenting Programmes to deaf children with emotional and behavioural problems, and autism, and their families: annotation and case report of a child with autistic spectrum disorder

This article describes a pilot project whose objective was to explore whether the Webster-Stratton Parenting Programme may be effective for hearing parents and their deaf children who present with conduct disorders and other emotional, behavioural and developmental problems. Outcome measures aimed at overall impact in decreasing behavioural problems and improving overall family function were used. Participants were hearing parents of deaf children referred to our specialist service whose assessment had recommended a parenting skills group as treatment of choice. The children had been diagnosed with behavioural problems with or without additional comorbidity. This pilot phase focused deliberately on one participant, in order to explore whether the approach justified further, more comprehensive evaluative research. Outcome was positive, suggesting that modified Webster-Stratton approaches may well be of use in deaf children of hearing parents.